By Onora O'Neill
Nuffield Council on Bioethics
Medical ethics is the most discussed field of bioethics, and has been mainly concerned with clinical ethics. It has often marginalized ethical questions about public health. A focus on the treatment of individuals has highlighted patient choice and informed consent. It can be widened to discuss the just distribution of health care, but is useless for considering many other interventions and policies that matter for public health. Many public health interventions are non-distributable goods, so cannot be allocated to individuals or subjected to individual choice requirements. In marginalizing public health, work in medical ethics also often marginalized questions about global health issues, where public health interventions matter hugely, and entrenched a deep separation of medical from environmental ethics.
Work that takes public and global health seriously needs to be anchored in political philosophy, to look beyond informed consent and individual choice, and to ask which interventions are permissible without the consent of those who they may affect, and which are not. Public health encompasses more than health 'promotion' and 'nudges' - and these too require justification - and even clinical interventions that are directed to individuals presuppose standards, technologies, and structures that cannot be matters of choice.
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